PC386 | 0611

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EVALUATION OF LOSS CONTROL PROGRAMS OF INSURANCE COMPANIES WRITING IN TEXAS

Commercial Automobile Liability Insurance

LOSS CONTROL INFORMATION WORKSHEET

PART A

1. a. Policy #: b. Policyholder Name:

c. Policy Eff. Date: d. Location Address:

e. # of Texas Locations: f. Est. Annual Premium: g. Insurance Company:

2. a. Radius of Operation: b. # of Drivers: c. Number & Type of Vehicles:

Current Policy Yr: 1st Prior Yr: 2nd Prior Yr:

3. Number of Occurrences/Claims: / / /

4. Frequency Indicator:

5. Loss Ratio:

6. Number of Visits:

7. Date of Last Loss Control Visit: 8. Worksheet Completed by: Date:_________

PART B

1. Description of operations (similar to that shown in industry guides; i.e. type cargo carried, number of miles driven per year, etc.):

2. List the potential risks/hazards associated with the operations of this policyholder that have or could cause a loss or claim.

3. Describe the types of losses experienced by this account, as reflected in Part A above, and any trends identified.

4. Describe the loss control measures taken by your company to control identified loss sources.

5. Training assistance and/or informational materials provided:

Have you provided training assistance to the insured?

If so, in what form? If not, for what reason (other than an insured not requesting assistance)?

(Continued)

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PC386 | 0611

Part B (Cont'd)

Have you provided loss control informational materials to the insured? If so, list the type of materials (i.e., mail-outs, pamphlets, etc.)

6. Does the insured have a formal (written) safety program?

If so, what is your opinion of it? Provide examples of different aspects of the program (or lack thereof) that caused you to reach this conclusion:

How was this information validated/confirmed (other than through application information submitted)?

7. Does the insured have a fleet maintenance program?

If not, what provisions have been made for the maintenance of vehicles?

What recommendations/assistance have you provided for the development or improvement of such a program?

8. Loss/accident investigation and analysis provided?

Describe the type of analysis conducted, its result/conclusions and the manner in which the results were presented to the insured.

9. Current status of this policyholder account:

Non-Renewed by company (explain circumstances) Cancelled by company (explain circumstances)

Non-Renewed by policyholder (explain circumstances) Current in-force policy

Instructions for Completing

Part A

1. a. Policy Number. b. Name of policyholder, e.g. "Acme Widget Company" c. Date current policy took effect. d. City in which policyholder's main office is located. e. Number of Texas locations f. Estimated annual premium for current policy year. g. The insurance company writing coverage.

2. a. The estimated range of operation for the vehicles insured. b. Number of drivers. c. Number and Type of Vehicles insured on the policy.

3. Number of occurrences/claims in the current policy year, 1st prior policy year, and 2nd prior policy year.

4. Frequency Indicator = Number of Occurrences X 100 Number of Vehicles

5. Loss Ratio = Incurred Losses_ (expressed as a percentage) Earned Premium

6. Number of visits to the account made by the Loss Control Representative in the current policy year, 1st prior policy year, and 2nd prior policy year.

7. Date of last loss control visit to, or direct communication with, the insured by a Loss Control Representative.

8. Name of person who has completed this worksheet followed by the date the worksheet was completed.

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Print: 1a Policy Number: 1b Policyholder Name: 1c Policy Eff Date: 1d Location Address: 1e Number of Texas Locations: 1f Estimated Annual Premium: 1g Insurance Company: 2a Radius of Operation: 2b Number of Drivers: 2c Number and Type of Vehicles: 2c Second Line: 2c Third Line: Number of Occurrences Current: Number of Claims Current: Number of Occurrences Prior: Number of Claims prior: Number of Occurrences 2nd Prior: Number of Claims second prior: 4: Frequency Indicator Current Policy Year: Frequency Indicator First Prior Year: Frequency Indicator Second Prior Year:

5: Loss Ratio Current Policy Year: Loss ratio First Prior Year: Loss Ratio Second Prior Year:

6: Number of Visits Current Policy Year: Number of Visits First Prior Year: Number of Visits Second Prior Year:

7: Date of last loss control visit:

8 Worksheet Completed by: Date worksheet completed: Description of operations: Potential risks: Types of losses: Loss control measures: Provided Training assistance: What type of assistance: Training assistance not provided: Loss control information: Type of assistance materials: Formal safety program: Opinion of safety program: Information validated: Fleet maintenance: Maintenance of vehicles: Improvement recommendations: Loss investigation: Analysis conducted: Check Box1: Check Box2: Check Box3: Check Box4: 9: Circumstances: